Medicare/Medicaid Fraud in McAllen, Texas

Medicare/Medicaid fraud is a federal offense that involves submitting false claims for reimbursement under the federal Medicare/Medicaid program. “Medicare/Medicaid fraud” is a broad term that can implicate civil or potentially even criminal liability under the False Claims Act, the Anti-Kickback Statute, the Stark Law, the U.S. Criminal Code, and other federal laws. However, despite the wide range of laws that may apply, the hallmark of any Medicare/Medicaid fraud case is an allegation that a health care service provider illegally received money from the federal government.

McAllen, Texas sees numerous Medicare/Medicaid fraud investigations every year. McAllen is home to many hospitals, hospices, and other health care providers that rely on Medicare/Medicaid reimbursements in order to serve their patients. Due to the sheer volume of reimbursement requests coming out of the McAllen region, the Centers for Medicare and Medicaid Services (CMS) is keenly focused on investigating suspected fraud in this area of Texas. In fact, McAllen is one of only nine U.S. cities in which the federal government has established a Health Care Fraud Prevention and Enforcement Action Team (HEAT) to monitor, investigate, and prosecute cases of suspected Medicare/Medicaid fraud. Medicare Fraud Strike Force is a coordinated federal task force composed of prosecutors from the Department of Justice (DOJ), Department of Health and Human Services (HHS), the Office of Inspector General (OIG), the Federal Bureau of Investigation (FBI), and others.

As a result, health care service providers in McAllen, Texas, and their executives, must be particularly vigilant about both (i) maintaining effective compliance programs to avoid raising suspicion of possible fraudulent billings, and (ii) taking action at the first sign of a potential Medicare/Medicaid fraud investigation. While you may not ultimately be able to avoid a disruptive investigation once HEAT has you in its sights, acting quickly will give you the best chance to avoid facing civil or criminal charges.

Forms of Medicare/Medicaid Fraud

As outlined above, Medicare/Medicaid fraud is a form of health care fraud that involves the submission of false or fictitious reimbursement claims to the federal government. In a typical Medicare/Medicaid Fraud investigation, the government will allege one or more of a variety of fraudulent billing practices. Some of the most-common examples include reimbursement requests for false, excessive, or unauthorized services involving:

Billing for services that were never performed (commonly referred to as “phantom billing”);

Providing and billing for services that were not medically necessary;

Billing for supplies and equipment that were not actually purchased;

Purchasing and billing for supplies and equipment that were medically unnecessary;

Obtaining fraudulent certifications for services that were medically unnecessary (a common allegation in home health and hospice fraud investigations);

Understanding the Penalties for Medicare/Medicaid Fraud

For those convicted or found liable of Medicare/Medicaid fraud, the consequences can be severe. The potential penalties for Medicare/Medicaid fraud include recoupment requests, non-payment of future claims, civil fines of up to $11,000 per false claim, treble damages, attorney fees, criminal fines, criminal indictment, and federal imprisonment. The standard prison sentences in Medicare/Medicaid fraud cases are:

Up to 10 years in prison for each count of fraud;

Up to 20 years in prison if the fraud resulted in serious bodily injury (most common in cases involving counterfeit and excessive medications); and,

Life imprisonment for fraudulent practices resulting in a patient’s death.

In addition, service providers and medical professionals can face exclusion from future participation in federal health care programs (including Medicare, Medicaid, and Tricare), and will often face licensing actions and loss of hospital privileges, as well.

Choosing the Right Defense Lawyer for Your Medicare/Medicaid Fraud Investigation

If you or your organization is under investigation for Medicare/Medicaid fraud, it is absolutely essential to select a law firm comprised of defense attorneys who have the skills and experience necessary to effectively represent you.

The Right Choice: A Team of Health Care Fraud Defense Lawyers.

You need health care defense law team with the right mix of health care law experience and a strong record in health care fraud defense. Before paying any money to a defense attorney, you should test the lawyer’s experience in Medicare/Medicaid Fraud cases with the following THREE GOLDEN QUESTIONS:

How many Medicare/Medicaid fraud cases have you handled so far?

How many of the health care fraud cases that you handled resulted in no civil and no criminal charges or dismissals for your clients?

How many health care fraud cases have you tried in court?

Proven Defense Strategies

Throughout their extensive careers, the attorneys of Oberheiden, P.C. have handled more than hundreds of health care cases and trials across the country. Many of our attorneys come from senior positions within the Department of Justice. While every case is different, based on our experience, the following defense strategies have proven to be extremely successful for helping our clients avoid criminal charges:

Early Intervention

To protect yourself, it is critical to engage with a legal defense team as soon as possible. The longer the government can investigate before you hire legal representation, the higher the chance there is that your case will turn into a criminal matter. Don’t let the government build its case. Hire lawyers with open channels with the government who can immediately initiate a dialogue with their government contacts and get fast answers to questions like:

What is this case about?

What prompted the investigation?

Is the case civil or criminal?

What agencies are involved?

Who else is under investigation?

What is the government’s ultimate goal?

We strive to provide our clients with these answers as soon as possible – often within the first hours of our engagement.

Lack of Evidence

The U.S. justice system places a heavy burden on the government to prove punishable misconduct. In fact, in order to find you guilty of Medicare/Medicaid fraud, the government must prove beyond a reasonable doubt that you committed an illegal act with criminal intent. Our attorneys put this constitutional standard to the test in every single case, often resulting in:

Case dismissed;

Avoidance of criminal charges;

Retain your professional license;

Civil fine and no criminal plea;

Misdemeanor, no felony; and

No prison time.

In the vast majority of cases in McAllen, Texas, the incidents that prompt Medicare/Medicaid fraud investigations originate from organizational and human errors, not criminal intent. These errors frequently occur because health care providers are focused on caring for their patients. In addition, targets of investigations almost always are experiencing rapid growth. In both scenarios, we commonly find the following causes for errors:

Unqualified staff;

Supervision errors;

Delegation & outsourcing;

Structural deficits;

Organizational mistakes;

Human error;

Oversight and overwhelmed;

Lack of compliance program; and

Constantly changing rules

While these may or may not be issues that require corrective action, one thing is clear: they do not constitute criminal intent.

Applicable Defenses

Finally, a thorough analysis will often reveal several favorable defenses that are available for clients facing Medicare/Medicaid fraud investigations. For example, in a recent Medicare/Medicaid fraud case that we handled, the government alleged that our client fraudulently certified the need for health care services. We convinced the government that a recognized exception of the statute applied, rendering the certification fully compliant with the law. In another case, we refused to admit liability and ultimately convinced the prosecutors that our client acted within a safe harbor exception.

About Oberheiden, P.C.

At Oberheiden, P.C., we represent business owners, health care executives, lawyers, health care providers, hospitals, pharmacies, laboratories, and other entities in the health care industry that find themselves under investigation for illegal kickbacks, fraudulent billing practices, and various other allegations of Medicare/Medicaid fraud. These include providing medically unnecessary services, billing for services not rendered, and unlawful joint ventures between referring physicians and ancillary-income businesses. Our practice areas include:

Health care fraud defense;

Compliance programs;

Internal investigations;

Qui tam defense;

Asset protection;

Licensure & disciplinary proceedings; and

Jury trials.

Our clients range from individual providers and executives to entire health care systems. We represent clients in McAllen, Texas who are under investigation by the Department of Justice, the Department of Defense, the Federal Bureau of Investigation, Drug Enforcement Administration, the Office of Inspector General, the Medicaid Fraud Control Unit, McAllen and Texas law enforcement, the Internal Revenue Service, and other state and federal agencies.

Our Track Record

Defense of Medicare/Medicaid laboratory against investigations by the Department of Justice and the U.S. Attorney’s Office for alleged Medicare/Medicaid fraud.Result: No civil or criminal liability.

Defense of a health care services company against an investigation by the Office of Inspector General, the Department of Justice, and the Department of Health and Human Services for alleged False Claims Act and Stark Law violations.Result: No civil or criminal liability.

Defense of Medicare/Medicaid laboratory against investigations by the Department of Health and Human Services and the Office of Inspector General for alleged health care fraud.Result: No civil or criminal liability.

Defense of nationally operating health care company against an investigation by the Department of Defense for alleged Tricare fraud.Result: No civil or criminal liability.

Defense of health care marketing company against an investigation by the Office of Inspector General for alleged False Claims Act and Medicare/Medicaid violations.Result: No civil or criminal liability.

Defense of a laboratory against an investigation by various branches of the federal government for alleged fraud.Result: No civil or criminal liability.

Defense of physician-owned entity against an investigation by the Department of Health and Human Services for alleged Stark Law violations.Result: No civil or criminal liability.

Defense of a physician-owned entity against an investigation by the Office of Inspector General for alleged fraud.Result: No civil or criminal liability.

Defense of a physician-owned entity against an investigation by the Department of Justice for alleged fraud.Result: No civil or criminal liability.

Defense of a physician-owned entity against an investigation by the Office of Inspector General for alleged Stark Law violations.Result: No civil or criminal liability.

Defense of a physician-owned entity against an investigation by the Office of Inspector General for alleged False Claims Act violations.Result: No civil or criminal liability.

Defense of a physician-owned entity against an investigation by various branches of the federal government for alleged False Claims Act, Stark Law, and Medicare/Medicaid violations.Result: No civil or criminal liability.

Defense of a physician-owned entity against an investigation by the Office of Inspector General for alleged fraud.Result: No civil or criminal liability.

Defense of a physician-owned entity against an investigation by the Department of Defense for alleged Tricare fraud.Result: No civil or criminal liability.

Defense of a physician-owned entity against an investigation by the Department of Justice for alleged Medicare/Medicaid fraud.Result: No civil or criminal liability.

Defense of physician-owned entity against an investigation by the Department of Health and Human Services for alleged Stark Law violations.Result: No civil or criminal liability.

Defense of health care management organization against an investigation by the Office of Inspector General, the Department of Justice, and the Department of Health and Human Services for alleged Medicare/Medicaid fraud.Result: No civil or criminal liability.

Defense of nationally operating laboratory against an investigation by the Office of Inspector General for alleged fraud.Result: No civil or criminal liability.

McAllen, Texas Health Care Fraud Defense Attorneys

Dr. Nick Oberheiden is a Harvard-trained and internationally educated health care fraud defense attorney. Dr. Oberheiden has successfully represented health care executives, business owners, public officials, physicians, and lawyers in high profile prosecutions, scores of political corruption, government investigations, and media campaigns, including 60 Minutes. He is best known for eliminating potential criminal charges in federal investigations. Dr. Oberheiden also leads internal investigations, implements corporate compliance programs, and teaches U.S. criminal law and federal litigation in the United States and abroad.

Lynette S. Byrd is a former Assistant United States Attorney (AUSA). Clients greatly benefit from Ms. Byrrd’s former experience of working with the Department of Justice, where she prosecuted health care fraud, Anti-Kickback violations, False Claims Act violations, and Stark violations on behalf of the United States. Ms. Byrd has valuable experience with health care law enforcement, and she regularly argues federal matters for her clients.

This information has been prepared for informational purposes only and does not constitute legal advice. This information may constitute attorney advertising in some jurisdictions. Reading of this information does not create an attorney-client relationship. Prior results do not guarantee similar future outcomes. Oberheiden, P.C. is a Texas firm with headquarters in Dallas. Mr. Oberheiden limits his practice to federal law.

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Oberheiden, P.C. is headquartered in Dallas, Texas, and it assists clients with audits, investigations, and trial work nationwide. Call one of us today and benefit from our experience and industry knowledge in a free and confidential consultation.

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